Seminole State College Phlebotomy Certificate Program Application for Admission

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1 Application for Admission The admits one new class each summer semester. Admission is limited to ten students per class. All applications must be submitted to the Program Director by April 15 th to be considered for admission. Upon meeting the requirements of the admission process, a selection committee reviews the applications and selects the class based on a point system. Primary selections and alternates are ranked by ACT scores, grade point average, and completion of interview with the Program Director. No one academic or nonacademic element may eliminate a student from consideration, but all are considered as sources for predictability of success. Requirements for Admission: Applicants must be 18 years or older. Be a high school graduate or have earned a high school equivalency diploma (GED). Have a GPA of 2.0 or higher on a 4.0 scale of the most recent academic transcript (high school or postsecondary if 12 or more hours have been completed). Submit; completed Phlebotomy Program application form completed application for admission to Seminole State College high school transcript or GED certificate all college transcripts copy of ACT scores (taken within the last 5 years) documentation of immune status OSBI background check Complete an interview with the Program Director. Sign the statement of understanding regarding admission policies and placement in clinical affiliates. Return all application material to: Seminole State College Malinda Browning, M.P.H., MLS(ASCP) CM Director P.O. Box 351 Seminole, Oklahoma Call (405) or m.browning@sscok.edu for appointments.

2 Application Form Legal Name First MI Maiden Last Permanent Address Street City/State Zip Telephone Number Cell Phone Number address Name and Location of high school attended Date of Graduation (if not a graduate, submit a copy of high school equivalency) 5. Have you ever been enrolled in a Phlebotomy Program? If yes: Where When Briefly state reason for non-completion Each applicant must read and sign the Statement of Understanding concerning potential health risks, requirements for proof of immunity, appointments to clinical sites, patient confidentiality and continuation and/or termination from the program.

3 Admission Policies Statement of Understanding I have made application to and have been admitted to Seminole State College as a full-time/parttime student. I have taken the ACT (within the last 5 years). I have read and understand the Alternate Status Policy for entering Clinical Practicum. I understand that an immunization record is due upon application and evidence of good health and immunity is required by the clinical affiliates before being accepted into Clinical Practicum. I understand that I am to pay a premium for personal liability coverage (Due upon enrollment into the ) I have had a personal interview with the Program Director. I understand a background check is required by all affiliate sites and is due at the time of application to the Phlebotomy Program. I understand clinical affiliates may require initial or random drug testing. I understand all patient information is confidential. Discussion of clinical experiences takes place only in clinical conferences or private conversations with the instructors. Students will be required by clinical agencies to complete requirements addressing Personal Health Information and the Health Insurance Portability and Accountability Act (HIPAA). Failure to comply with this policy will be grounds for immediate dismissal from the Phlebotomy program. I understand this course has three components; student lectures, student labs and the clinical practicum. Successful completion of the student lectures, and student labs with a C or better is required before entering the clinical practicum component of the class.

4 Student Health Screening Phlebotomy is a profession in which the healthcare workers may be exposed to infectious materials, such as blood, body fluids, as well as needles. Every precaution is taken to prevent any contact which might endanger the health of the phlebotomist. Some of the best means of prevention are immunizations and recovery from the disease. In order to comply with the mandatory health requirements, you must provide official documentation of your immune status by providing one of the types of documentation as listed on the next page. Indicate which type of documentation you are providing by placing the dates in the columns provided and attach copies of all documentation to verify dates. If there is any question concerning immunity, tests for immune status (titer) and immunizations may be done at the county health department. Documentation of immunity must be provided upon application to the Phlebotomy Certificate Program and a copy of these records must be in your phlebotomy student file. CPR certification is recommended and may also be required by clinical affiliates. Check with the MLT department for current requirements. I understand that I am responsible for reporting any health problems that occur to me while I am in clinicals to my immediate supervisor. It is further understood that I may be asked to withdraw if the safety of my health or that of a patient is endangered. The Phlebotomy faculty retains the option of requiring a physician's release before allowing a student to begin or to return to clinicals. Student Student Signature Date of Birth Date Phlebotomy Faculty Review Date

5 Name: Seminole State College Documentation of Immune Status Home Phone( ) Cell Phone( ) Date of Birth Address City State Zip Code Please provide a copy of your documented immunity to the following: Date Date Date I. Proof of 2 TB Skin Test (PPDs) within the last 365 days or Chest X-ray (if positive reactor) II. Proof of Rubella (3-day) Measles: B. Documented evidence of Rubella vaccination on or after 12 months of age. III. Proof of Rubeola (Hard) Measles: B. Documentation of receipt of 2 doses of Measles vaccine on or after 12 months of age for individuals born during or after IV. Varicella-zoster (Chickenpox) Immunity: B. Personal history of disease. C. Documentation of receipt of 2 doses of Varicella vaccine. V. Mumps Immunity: B. Documented evidence of Mumps vaccination on or after 12 months of age. VI. Hepatitis B Vaccine: B. Documented evidence of 3 doses received. C. Declination form signed/copy attached. Student Signature: Date:

6 Selection Process During the interview with the Phlebotomy Program Director, each prospective Phlebotomy applicant is advised of the policies for admission to the program. Selection for admission will be made by the Phlebotomy Review Committee using the following criteria: High School Grade Point Average (If less than 12 college credit hours) = 4 points = 6 points = 8 points = 10 points College Grade Point Average = 4 points = 6 points = 8 points = 10 points ACT score (Composite after 1989) = 4 points = 6 points = 8 points = 10 points ACT score (Math and/or Science Score) = 4 points = 6 points = 8 points = 10 points Interview Motivation (0-5 points) Communication Skills (0-5 points) Background knowledge about the profession (0-5 points) Total Points All interviewed applicants will be notified by mail regarding their selection status. The successful applicants will be notified before summer enrollment begins. Acceptance to Seminole State College does not guarantee admission into the Phlebotomy Program.

7 Alternate Status Policy The of Seminole State College has clinical affiliates where students will complete 100 hours of clinical experience and 100 successful phlebotomy procedures. The time required to complete the clinical practicum varies due to the schedule of rotations. In order to provide quality one on one instruction, affiliates have agreed to take a limited number of students per semester. Successful completion of the on-campus lecture and lab component of the class with a C or better is required before continuing to the clinical practicum. More students may be ready for Clinical Practicum than there are openings available. Therefore, it is possible that students may have to wait two or more weeks to begin a clinical practicum. In the event that more students are prepared than there are clinical openings, the order of priority exists as follows: Students will be ranked according to;. 1. Average test score in the on-campus lecture and lab component of Phlebotomy course. 2. Composite ACT score. 3. GPA of the most recent academic transcript (high school or postsecondary if 12 or more hours have been completed). 4. Number of absences in the on-campus lecture and lab component of the Phlebotomy course. Students will be placed in Clinical Practicum as soon as an available space occurs. Students will be notified in writing of their status. The Program Director attempts to place students in the affiliate nearest their home if that is possible. Transportation is the responsibility of the student. I have read and understand the Alternate Status Policy and agree to work with the Phlebotomy Program Director to complete my certificate requirements. Signature of Student Date This document will become part of your personal file.

8 Standards for Essential Technical Skills There are certain skills that are essential to be successful in this profession. Listed below are those skills that will be evaluated during and upon completion of the program. 1. Communicate in English with instructors, patients and other medical personnel. 2. Communicate politely and effectively lab results over the telephone. 3. Use digital fine motor skills with both hands continually throughout the day to apply and release tourniquets, palpate veins, use venipuncture equipment (such as vacuum tubes and holders, syringes and butterfly needles), and skin puncture equipment. 4. Safely perform a venipuncture. 5. Safely perform a skin puncture. 6. Transfer blood from a syringe to various blood collection tubes. 7. Safely dispose of contaminated sharps. 8. Correctly identify the patient and label the tubes of blood. 9. Must be able to see clearly enough to read hand-written and computer-generated communications. 10. Must be able to transfer names and copy numbers precisely in logs or on report forms. 11. Possess organizational skills to determine when blood samples need to be collected, order of draw and fill, proper timing of draws and deliveries. 12. Walk to and from patient service areas of the hospital for the majority of the day. 13. Help patients in and out of phlebotomy chairs and tables. 14. Apply safety and infection control standards learned in the program to maintain a safe and clean environment for patients and self. These skills will be demonstrated in the phlebotomy class and all students will be expected to become proficient in each by the completion of the clinical practicum. I have read and understand the selection process Name Date This document will become a part of your personal file. Admission to the is open to all qualified applicants regardless of economic or social status, and without discrimination on the basis of race, color, sex, marital status, beliefs, age, national origin, or handicap. MSWord:PBT admission form.doc 2/2011

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